Forms For South Dakota
Insured through:
Wellmark Blue Cross Blue Shield of South Dakota
Member Submitted Claim Form PDF File
Blue Cross Blue Shield Global® Core Claim Form:
Application for MedicareBlue Supplement℠
- For plans effective prior to January 1, 2020 PDF File
- For plans effective January 1, 2020 and after PDF File
Authorization for Automatic Account Withdrawal PDF File
Application for Fidelity Security Life Insurance Company Vision and Hearing PDF File
Choosing a Medigap Policy: A Guide to Health Insurance for People with Medicare External Site
Reporting Health Care Fraud & Abuse
Agent/Agency of Record Transfer Request PDF File
Appeal Form PDF File
See also How to Appeal
File an External Review - South Dakota Division of Insurance External Site
Authorization for Disclosure to Housing Authority PDF File
This form is used to authorize Wellmark to disclosure premium information to a housing authority at the request of the individual.
Authorization to Use or Disclose Protected Health Information PDF File
This form is used to authorize Wellmark to release protected health information to an individual or entity other than yourself.
Personal Representative Appointment and Authorization to Release Protected Health Information PDF File
This form is used to appoint someone to act on your behalf, as well as to authorize Wellmark to release protected health information to them.
